Exam 2 Ch. 39

24問 • 3年前

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1. The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient’s albumin level is critically low. What assessment finding will the nurse expect to note when assessing the patient?

a. The patient has generalized 3+ pitting edema.

2. The nurse is reviewing the patient’s laboratory results. Which result must be communicated to the physician immediately?

c. Serum potassium level 6.8 mEq/L

3. The nurse is caring for a patient who is at risk for fluid overload due to a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?

b. “Weigh yourself every morning before breakfast.”

4. The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient’s body to correct the pH?

a. The patient’s respirations are very deep and rapid.

5. The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur due to this therapy?

c. Hypokalemia

6. The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient’s arrival to the hospital. Which results will the nurse expect to see?

d. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg

7. The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. The nurse knows which condition to be the most likely cause of the patient’s collapse?

a. Orthostatic hypotension

8. The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the patient’s chart as the underlying cause of these results?

a. Gastroenteritis with severe nausea, vomiting, and diarrhea

9. The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of the three meals and had another 150 mL with medication administration. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume to stay within the prescribed fluid restriction?

b. 150 mL

10. The nurse is caring for a patient who has a history of heart failure. The nurse includes the diagnosis hypervolemia in the patient’s care plan. Which goal statement has the highest priority for the patient and nurse?

a. The patient’s lung sounds will remain clear.

11. The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient to correct the patient’s fluid imbalance?

d. 3% normal saline

12. The nurse is caring for a patient with heart failure who requires intermittent IV bolus doses of furosemide (Lasix) to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert to administer the patient’s medication?

d. Over-the-needle catheter

13. The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient’s plan of care?

b. Use strict sterile procedure when performing dressing changes.

14. The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse’s best action?

a. Discontinue the IV and start another line in the other arm.

15. The nurse is caring for a patient who is to receive dopamine (Intropin) through the IV line. Which intervention has the highest priority when administering this medication?

a. Check for IV blood return prior to administration.

16. The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?

b. Assess the patency of the current IV site for the administration of the packed RBCs.

17. The nurse is caring for a patient who is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient’s blood pressure decreases significantly, and the patient complains of shortness of breath. What is the priority action of the nurse?

c. Stop the blood transfusion and administer 0.9% normal saline through new IV tubing.

18. The nurse is caring for a patient who is very dehydrated. Which goal best indicates that dehydration has been corrected and that the patient’s fluid balance has been restored?

a. The patient had 1300 mL of light yellow urine in the last 24 hours.

19. The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?

a. Perform regular neurologic checks and institute seizure precautions.

20. The nurse is caring for a patient who has a history of congestive heart failure and takes a once-daily loop diuretic to prevent fluid overload and pulmonary edema. The patient admits to stopping the medication due to nocturia. What is the nurse’s best response?

b. “Take the diuretic early in the morning before breakfast.”

21. The nurse is caring for a patient with renal failure who has a serum potassium level of 7.1 mEq/L and serum magnesium level of 3.5 mEq/L. The nurse prepares to administer 10 units of insulin and an ampule of 50% dextrose to the patient. The patient asks why he will be receiving insulin when he is not diabetic. What is the nurse’s best answer?

b. “These medications will lower your potassium level and prevent an irregular heart rate.”

22. The nurse is caring for a patient with a history of hyperparathyroidism who presents with a serum calcium level of 14.5 mg/dL. What is the highest priority nursing diagnosis for this patient?

a. Risk for injury related to weakened bones that may easily fracture.

23. The nurse is caring for a patient who has a serum magnesium level of 0.8 mEqL. Which is the highest priority goal to include in the patient’s plan of care?

d. The patient will remain alert and oriented 3 with no confusion or seizure activity.

24. The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium level of 14.2 mg/dL. What is the priority intervention of the nurse?

a. Instruct the patient to always call for assistance before getting out of bed.

NUR 170 exam 4

V Farris · 50問 · 3年前

NUR 170 exam 4